Medicare Compensation Recovery

Third party authority (MO021)

When to use this form Filling in this form

This form is to be completed by the injured person or claimant (such
• Use black or blue pen.
as a legal representative) who is seeking compensation on behalf of
the injured person. • Print in BLOCK LETTERS.
• Where you see a box like this Go to 1 skip to the question
By completing this form, the injured person or claimant gives the
number shown. You do not need to answer the questions in
Australian Government Department of Human Services authority to
between.
release compensation information to a third party and gives
permission for a third party to sign relevant documentation on their
behalf. The third party must agree to act for the injured person or Medicare compensation case reference number
claimant by signing the declaration in this form.
1 Provide the Medicare compensation case reference number
Authorising a third party to sign Medicare Compensation Recovery
(if known)
documentation on your behalf means that you will be bound by their
actions.
Any changes to this authority or any other authority/implied consent
in relation to this case can only be revoked in writing. Injured person’s details
This authority is valid up to and including the date the case is
finalised by Human Services, unless otherwise revoked in writing by
2 Is the injured person listed on a Medicare card?
the injured person or claimant. No
Yes Provide Medicare card number Ref no.
Definitions
Injured person is the person in respect of whose injury or illness the
compensation may be paid. 3 Dr Mr Mrs Miss Ms Other
Claimant is the person seeking compensation either on his or her Family name
own behalf or on behalf of another person.
Legal representative is the person who has been appointed by law First given name
to act on the injured person’s behalf (such as an executor, court
order, Power of Attorney).
Third party is either an organisation (such as a solicitor) or an Second given name
individual (such as a friend or relative) who is being authorised in
this form to act on behalf of the injured person or claimant.
4 Date of birth
For more information / /
Go to humanservices.gov.au/medicarecompensationrecovery or
www.

5 Postal address
email compensation.recovery@humanservices.gov.au or
call 132 127.
Note: Call charges may apply.
Postcode

6 Daytime phone number

( )

Mobile phone number

7 Date of injury or illness

/ /

MO021.1906 1 of 3
8 Is this form being completed on behalf of the injured person who: Third party’s details
• is under 14 years of age
• does not have the capacity to act on their own behalf, or 12 Authorised third party’s case reference (if known)
• is deceased?
No Go to 12 13 Business name (if applicable)
Yes Give details of the relationship to the injured person
(for example, parent, guardian or legal representative)

14 Dr Mr Mrs Miss Ms Other

Authorised third party’s family name

If this claim is being made on behalf of

someone 14 years of age or over who First given name
does not have the capacity to act on
their own behalf or is deceased, provide
supporting documentation (Power of
Attorney, court order, Last Will and Second given name
Testament, probate).
Go to next question 15 Postal address

Claimant’s details

9 Dr Mr Mrs Miss Ms Other Postcode

Family name or business name (if applicable) 16 Daytime phone number
( )
First given name Mobile phone number

Second given name

Privacy notice
10 Postal address 17 Your personal information, and the personal information of
others that you provide, is protected by law, including the
Privacy Act 1988. The Australian Government Department
of Human Services collects this personal information for the
Postcode purposes of administering the
Health and Other Services (Compensation) Act 1995.
11 Daytime phone number Human Services may collect personal information about the
( ) injured person from the injured person’s and/or claimant’s
authorised third party and from the relevant notifiable person or
Mobile phone number compensation payer.
Human Services may disclose the injured person’s personal and
sensitive information to the claimant, authorised third party and
the relevant notifiable person or compensation payer.
Information that may be disclosed includes information
contained in a Medicare history statement, notice of past
benefits and notice of charge, as well as information about
relevant events relating to the injured person’s compensation
claim. In addition, Human Services may disclose the injured
person’s personal and sensitive information to the Department
of Health for the purposes of determining the injured person’s
eligibility for payments and services under the
Aged Care Act 1997.
Your information may also be used by Human Services or given
to other parties for the purposes of research, investigation or
where you have agreed or it is required or authorised by law.
You can get more information about the way in which
Human Services will manage your personal information,
including our privacy policy at humanservices.gov.au/privacy
www.

or by requesting a copy from Human Services.

MO021.1906 2 of 3
Injured person’s or claimant’s declaration
18 I authorise:
• the third party (as referenced in the Third party’s
details section) to act on my behalf in relation to my
claim for compensation under the Health and Other
Services (Compensation) Act 1995. This includes receiving
documents from the Australian Government Department of
Human Services, viewing/modifying my record, completing
all functions in relation to my claim for compensation and/
or signing all relevant documents in relation to my claim for
compensation.
I declare that:
• the information I have provided in this form is complete and
correct.
I understand that:
• giving false or misleading information is a serious offence.
Injured person’s or claimant’s full name
Returning your form
Check that all required questions are answered and that the form
is signed and dated. Answering all questions may not be required,
however where required information is incomplete, it may cause
processing delays.
Return the completed form and any supporting documents by:
• email to compensation.recovery@humanservices.gov.au
Note: There may be risks associated with sending
personal information through unsecured networks or
email channels.
• fax to 07 3004 5406
• post to Department of Human Services
Medicare Compensation Recovery
GPO Box 2436
BRISBANE QLD 4001

Injured person’s or claimant’s signature

- On completion, print and sign by hand.

Date
/ /

Authorised third party’s declaration

IMPORTANT: Make sure you read the Privacy notice at
question 17 before you complete this declaration.

19 I declare that:
• I undertake to act as an authorised third party for the
injured person or claimant.
Authorised third party’s full name

Authorised third party’s signature

- On completion, print and sign by hand.

Date
/ / Reset form Print form

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